Health Care Needs and Support for Patients Undergoing ...

RESEARCH ARTICLE

Health Care Needs and Support for Patients

Undergoing Treatment for Prosthetic Joint

Infection following Hip or Knee Arthroplasty: A

Systematic Review

Setor K. Kunutsor☯, Andrew D. Beswick, Tim J. Peters, Rachael Gooberman-Hill, Michael

R. Whitehouse, Ashley W. Blom, Andrew J. Moore*☯

Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom

☯ These authors contributed equally to this work.

* [email protected]

Abstract

Background

Hip and knee arthroplasty are common interventions for the treatment of joint conditions,

most notably osteoarthritis. Although many patients benefit from surgery, approximately 1%

of patients develop infection afterwards known as deep prosthetic joint infection (PJI), which

often requires further major surgery.

Objective

To assess support needs of patients undergoing treatment for PJI following hip or knee

arthroplasty and to identify and evaluate what interventions are routinely offered to support

such patients.

Design

Systematic review

Data sources

MEDLINE, EMBASE, Web of Science, PsycINFO, Cinahl, Social Science Citation Index,

The Cochrane Library, and reference lists of relevant studies from January 01, 1980 to Octo-

ber 05, 2016.

Selection criteria

Observational (prospective or retrospective cohort, nested case-control or case-control)

studies, qualitative studies, or clinical trials conducted in patients treated for PJI and/or other

major adverse occurrences following hip or knee arthroplasty.

PLOS ONE | DOI:10.1371/journal.pone.0169068 January 3, 2017 1 / 12

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OPENACCESS

Citation: Kunutsor SK, Beswick AD, Peters TJ,

Gooberman-Hill R, Whitehouse MR, Blom AW, et

al. (2017) Health Care Needs and Support for

Patients Undergoing Treatment for Prosthetic Joint

Infection following Hip or Knee Arthroplasty: A

Systematic Review. PLoS ONE 12(1): e0169068.

doi:10.1371/journal.pone.0169068

Editor: Robert K. Hills, Cardiff University, UNITED

KINGDOM

Received: April 4, 2016

Accepted: November 24, 2016

Published: January 3, 2017

Copyright: © 2017 Kunutsor et al. This is an open

access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information

files.

Funding: This paper presents independent

research supported by North Bristol NHS Trust

(NBT) Research and Innovation (R&I) Research

Capability Funding awarded to A.J.M. The funders

had no role in study design, data collection and

analysis, decision to publish, or preparation of the

manuscript. The views expressed in this

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http://creativecommons.org/licenses/by/4.0/

Review methods

Data were extracted by two independent investigators and consensus was reached with

involvement of a third. Given the heterogeneous nature of study designs, methods, and lim-

ited number of studies, a narrative synthesis is presented.

Results

Of 4,213 potentially relevant citations, we identified one case-control, one prospective

cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and

treatment had a profoundly negative impact affecting physical, emotional, social and eco-

nomic aspects of their lives. No study evaluated support interventions.

Conclusion

The findings demonstrate that patients undergoing treatment for PJI have extensive physical,

psychological, social and economic support needs. The interpretation of study results is limited

by variation in study design, outcome measures and the small number of relevant eligible stud-

ies. However, our review highlights a lack of evidence about support strategies for patients

undergoing treatment for PJI and other adverse occurrences following hip or knee arthroplasty.

There is a need to design, implement and evaluate interventions to support these patients.

Systematic Review Registration

PROSPERO 2015: CRD42015027175

Introduction

Joint arthroplasty is a common surgical procedure, with over 185,000 primary hip and knee

arthroplasties performed in England, Wales and Northern Ireland in 2014 [1, 2]. After total hip

or knee arthroplasty, about 1% of patients develop an infection of their new, artificial joint [3,

4]. This is known as prosthetic joint infection (PJI). When PJI is identified, further major opera-

tions are commonly needed to clear the infection, which reduces the need for subsequent joint

removal or even limb amputation. Surgical treatment involves extensive debridement with

either prosthesis retention or surgical revision with a new prosthetic joint inserted either imme-

diately (one-stage procedure) or after a delay, typically between 3 and 6 months (two-stage pro-

cedure). If delayed, a temporary implant or “spacer”, often impregnated with antibiotics may be

fitted; however further complications including spacer dislocations and femoral fractures are

common with the use of such spacers [5]. Surgical treatments are used in conjunction with the

use of powerful intravenous and oral antibiotics. After revision surgery has been performed,

reinfection occurs within two years in around 8% of patients requiring further major surgery,

lifelong antibiotic suppression or amputation [6–8]. Although PJI affects a small percentage of

patients, hip and knee replacements are common and PJI is considered to be one of the most

devastating complications associated with this procedure [9]. It typically presents with a leaking

wound or onset of fever, pain, swelling, worsening joint pain and restriction of movement and

may develop into systemic sepsis [10, 11]. If left untreated, the condition can cause death [12].

Research evidence on the treatment of prosthetic joint infection has focussed on the clinical

effectiveness of different types of revision surgery [6–8] while there appears to be less focus on

the impact on patients and their support needs. During the hospital discharge process, patients

Health Care Support for Prosthetic Joint Infection


publication are those of the author(s) and not

necessarily those of the NHS, NBT, or R&I.

Competing Interests: The authors have declared

that no competing interests exist.

receiving orthopaedic interventions, including total hip and knee replacements, report a nega-

tive mental outlook, functional and activity limitations, pain and loss of independence [13].

After a range of hospital admissions, individualised discharge planning strategies may lower the

risk of readmission and improve patient satisfaction [14]. Post-discharge support for patients

treated with revision surgery is not currently included in clinical guidelines [15, 16]. However,

recognising their importance in other conditions with a high risk of a poor outcome such as

congestive heart failure [17] and chronic obstructive pulmonary disease, [18] there is a pressing

need to identify the support needs of patients with PJI and to provide effective support. Such

information can be used to design or improve services that may deliver benefit for patients.

The Medical Research Council (MRC) guidance on developing complex interventions sug-

gests that the first step in the development process is “to identify what is already known about

similar interventions and the methods that have been used to evaluate them. If there is no

recent, high quality systematic review of the relevant evidence, one should be conducted and

updated as the evaluation proceeds” [19]. In line with the MRC guidance we used a systematic

review approach; the primary aim of which was to assess support needs and care pathways for

patients undergoing treatment for PJI. However, given that the treatment burden and support

needs of these patients may share similarities with other adverse occurrences following joint

replacement, for example recurrent dislocation, we aimed to include other major adverse

occurrences following hip and knee arthroplasty that would also have a high chance of revision

surgery and a similar impact on the patient. Our search strategy was therefore widened to

include joint dislocation, fracture, pseudotumour, prosthesis failure, aseptic loosening and sep-

tic arthritis. This would allow us to define the extent of unmet needs for patients with PJI after

hip and knee arthroplasty and to evaluate existing support interventions for patients with PJI

or conditions with a similar impact that might prove useful in the development of a new care

pathway. Finally, we also sought to identify gaps in the available literature.

Methods

Data sources and search strategy

This review was conducted using a predefined protocol, which was registered in the PROS-

PERO prospective register of systematic reviews (CRD42015027175) and in accordance with

PRISMA guidelines [20] (S1 Appendix). We systematically searched MEDLINE, EMBASE,

Web of Science, PsycINFO, Cinahl, Social Science Citation Index, and the Cochrane Library

from 1980 to October 05, 2016 for observational (prospective cohort, nested case-control,

case-control, and retrospective cohort) studies, qualitative studies, and clinical trials that have

reported on the support needs and interventions for patients being treated for PJI or other

major adverse occurrences following joint arthroplasty. The computer-based searches com-

bined free and MeSH search terms and combination of key words related to support and care

pathways (including physical rehabilitation, counselling, peer support, improved information)

and adverse outcomes (including periprosthetic joint infection, dislocation, aseptic loosening)

without language restriction. We adapted the MEDLINE search strategy to the other databases

using the appropriate controlled vocabulary. Reference lists of retrieved articles were manually

scanned for relevant additional studies missed by the electronic search. Details on the search

strategy are provided in S2 Appendix.

Eligibility criteria

Studies were eligible if they reported on i) support needs (patient identified needs associated

with the outcomes of joint arthroplasty) and interventions (including physical rehabilitation,

counselling, peer support, improved information) for ii) adult patients (� 18 years) iii)



undergoing treatment for PJI or other major adverse occurrences (joint dislocation, fracture,

pseudotumour, prosthesis failure, aseptic loosening, and septic arthritis) iv) following joint

arthroplasty or revision surgery.

Data extraction and quality assessment

One reviewer (S.K.K.) initially performed screening of abstracts and potentially relevant arti-

cles were acquired. We then retrieved full text articles of these studies to determine whether

they met all inclusion criteria, which was conducted independently by two reviewers (S.K.K.

and A.J.M.). Disagreements and uncertainties were resolved by discussion, with the involve-

ment of a third reviewer (A.D.B) if necessary. A standardized predesigned data collection form

was used for data extraction. Data were abstracted, where available, on study design, baseline

population characteristics, geographical location, year of recruitment, percentage of males,

mean age, description of complication after joint arthroplasty, treatment for complication, and

number of participants. For studies with a prospective cohort design, methodological quality

was assessed based on the Methodological Index for Non-Randomised Studies (MINORS), a

validated instrument that is designed for assessment of methodological quality of non-rando-

mised studies in surgery[21]. For non-comparative studies, it uses eight pre-defined domains

namely: a clearly stated aim, inclusion of consecutive patients, prospective collection of data,

endpoints appropriate to the aim of the study, unbiased assessment of the study endpoint, fol-

low-up period appropriate to the aim of the study, loss to follow-up less than 5%, and prospec-

tive calculation of the study size. For each item, MINORS assigns 0 for not reported, 1 for

reported but inadequate, or 2 for reported and adequate. The global ideal score is 16. For the

study with a case-control design, study quality was assessed based on the nine-point Newcas-

tle–Ottawa Scale (NOS) [22] using three pre-defined domains namely: selection of participants

(population representativeness), comparability (adjustment for confounders), and ascertain-

ment of outcomes of interest. The NOS assigns a maximum of four points for selection, two

points for comparability, and three points for outcome. Nine points on the NOS reflects the

highest study quality. A critical appraisal of included qualitative studies was conducted using

the Specialist Unit for Review Evidence (SURE) Checklist [23]. This tool comprises of 10 ques-

tions that address broad issues such as clearly defined research questions, methodology, and

validity of results. We considered the characteristics of each study in relation to each of these

questions. Based on these characteristics the articles were classified as ‘fully address SURE

questions’ if they attended to all of the questions, ‘mainly address SURE questions’ if they

attended to most of the questions, or ‘partially address SURE questions’ if they attended to

some of the questions.

Data synthesis and analysis

It was not possible to calculate summary measures across studies given the limited number of

studies, diversity of the study designs, and the heterogeneous nature of the outcomes. The

characteristics of each study were summarised in a table. A narrative synthesis with separate

results from each study was therefore performed. For the above reasons, subgroup and sensi-

tivity analyses, and exploration of heterogeneity could not be conducted.

Results

Study identification and selection

Our initial search of databases and manual screening of reference lists of relevant studies iden-

tified 4,213 potentially relevant citations. After screening based on titles and abstracts, 12



articles remained for further evaluation. Following detailed assessments by two reviewers,

eight articles were excluded (S3 Appendix), while four studies met the inclusion criteria and

were included in the review (Fig 1).

Study characteristics and quality

Table 1 summarises the key characteristics of the four studies included in the review [24–27].

The studies were conducted in the USA, Australia, Sweden and the United Kingdom. Two

studies employed qualitative designs, one was a prospective cohort and the other was a case-

control study. All included studies were judged to be of adequate (moderate to high) methodo-

logical quality.

Fig 1. PRISMA Flow Diagram.

doi:10.1371/journal.pone.0169068.g001



Tab

le1.

Su

mm

ary

ch

ara

cte

risti

cs

ofin

clu

ded

stu

die

s.

Lead

au

tho

r,

pu

blicati

on

date

Lo

cati

on

Baselin

e

year

of

stu

dy

Stu

dy

desig

nP

op

ula

tio

nM

ale

s(%

)M

ean

/med

ian

ag

e(y

ears

)

Ad

vers

e

ou

tco

me

aft

er

join

t

art

hro

pla

sty

Tre

atm

en

t

for

ad

vers

e

ou

tco

me

Nu

mb

er

of

part

icip

an

ts/

join

ts

Stu

dy

qu

ality

Barr

ack,

2000

US

AN

RP

rospective

cohort

Patients

who

underw

ent

septic

and

aseptic

revis

ion

afterto

talk

nee

art

hro

pla

sty

NR

69.2

(68.5

for

septic

revis

ion

and

69.5

for

aseptic

revis

ion)

Infe

ction,aseptic

com

ponent

loosenin

g,

pro

gre

ssiv

e

oste

oly

sis

,and

com

ponent

insta

bili

ty

Tw

o-s

tage

revis

ion

125

patients

com

prisin

gof127

knees

(28

infe

cte

dand

99

notin

fecte

d)

11

Cahill

,2008

Austr

alia

2003–

2004

Case-c

ontr

ol

Patients

with

and

withouta

com

plic

ation

of

deep

infe

ction

afterT

JA

46.9

(43.5

for

uncom

plic

ate

d

and

52.9

for

com

plic

ate

d)

71.0

(71.0

for

uncom

plic

ate

d

and

71.0

for

com

plic

ate

d)

Deep

infe

ction

Washout/

antibio

tic;

two-s

tage

revis

ion;and

excis

ion

96

patients

(62

uncom

plic

ate

d

and

34

com

plic

ate

d)

5

Anders

son,

2010

Sw

eden

NR

Qualit

ative

descriptive

Part

icip

ants

dia

gnosed

with

deep

SS

I

64.3

NR

Deep

SS

IN

R*

14

Fully

addre

ss

SU

RE

questions

Moore

,2015

United

Kin

gdom

2014

Qualit

ative

sem

istr

uctu

red

inte

rvie

ws

Patients

who

had

underg

one

surg

icalr

evis

ion

treatm

entfo

r

PJI

63.2

73.2

PJI

One-and

two-s

tage

revis

ion

19

Fully

addre

ss

SU

RE

questions

*,in

dic

ate

dth

atpatients

had

receiv

ed

and

com

ple

ted

active

treatm

ent;

NA

,notapplic

able

;N

R,notre

port

ed;P

JI,

pro

sth

etic

join

tin

fection;S

SI,

surg

icals

ite

infe

ction;T

JA

,to

talj

oin

t

art

hro

pla

sty

.

doi:10.1

371/jo

urn

al.p

one.

0169068.t001



Support needs

Barrack and colleagues prospectively followed 125 patients who had a revision total knee arthro-

plasty for a minimum of two years and compared patient satisfaction, social functioning, and

functional outcomes between a group revised for infection and a group revised for reasons

other than infection [25]. Patients in the two groups expressed an equal degree of satisfaction

with their treatment; however, patients revised for infection reported lower functional outcomes

and were less likely to return to their normal activities of daily living. Cahill and colleagues

compared patient satisfaction, function, and health-related quality of life among patients with

uncomplicated joint replacements and joint replacements complicated by deep infection [24].

Questionnaires were administered to patients by phone and during face-to-face interviews.

Treatment options for patients with infection included washout with antibiotics, two-stage revi-

sion, and excision. Overall, patients in the group with deep infection had poorer functional and

health-related quality-of-life outcomes compared to the group without deep infection. Infection

greatly impacted on their physical and social functioning, their ability to live independently and

to perform activities of daily living. In their qualitative study, Andersson and colleagues aimed

to describe patients’ experiences of acquiring a deep surgical site infection (SSI) [26]. They ana-

lysed data from 14 open-ended interviews with participants who were diagnosed with a deep

SSI and had completed treatment. Of the 14 participants interviewed 12 acquired infection after

lower limb operations, 1 after coronary bypass and 1 after abdominal hysterectomy. The overall

results demonstrated that patients with infection and undergoing treatment experienced nega-

tive and often persistent changes in their lives, notably in relation to pain, social isolation, sense

of security, physical, economic and social wellbeing. The study also showed inconsistencies in

care and absence of adequate patient-healthcare professional relationships. The authors called

for strategies to support patients undergoing treatment for infection and the need to involve

patients in their care. In their qualitative interview study, Moore and colleagues aimed to char-

acterise the impact and experience of PJI and treatment on patients, including a comparison of

one- and two-stage revision treatment [27]. They analysed data from 19 interviews with partici-

pants with PJI (one-stage revision n = 9, and two-stage revision n = 10). Infection and treatment

occurred over periods ranging from 12 months to more than 10 years. The number of revision

operations received ranged from one to 15. Patients described loss of physical function and

mobility in relation to the infection and the treatment. Those who received a two-stage revision

reported additional challenges related to the interim period during which they had no pros-

thetic hip joint when either a spacer was fitted or not. Those left without a spacer faced consid-

erable physical and psychological difficulties. One patient reported considering suicide during

this period. Other patients who were fitted with a spacer for a period ranging from 10 weeks to

14 months, reported complications associated with the spacer including pain, immobility,

fracture and dislocation which caused further physical and psychological trauma. The overall

impact of PJI and treatment had a profound impact on physical, emotional, social and eco-

nomic aspects of patients’ lives. Patients also reported financial and employment difficulties

resulting from PJI. Support needs identified by participants included individualised physiother-

apy, psychological support and counselling and allied professional aftercare (osteopathy, podia-

try), home care and support in caring for others. Patients also identified a need for additional

information about the interim period of a two-stage revision.

Support interventions

No study evaluated any support interventions (including physical rehabilitation, counselling,

peer support, improved information) for patients being treated for PJI or other major adverse

occurrences following joint arthroplasty.



Excluded studies

The list of excluded studies after full text evaluation is provided in S3 Appendix. The majority

of these articles focused on the impact of preoperative clinical pathways on major outcomes

after joint arthroplasty. One was a quantitative review of 22 studies that evaluated the impact

of clinical pathways compared to standard medical care, on postoperative complications, qual-

ity of care, and direct costs after hip and knee joint arthroplasties.

Discussion

Key findings

Using a systematic review approach, we have assessed evidence on the support needs and sup-

port interventions for patients being treated for PJI and other major adverse occurrences fol-

lowing joint arthroplasty. In a comprehensive search of several databases, only four studies

were eligible and were included in the review. While all included studies focussed on support

needs for patients with PJI, one study also included patients with adverse outcomes such as

aseptic component loosening and component instability [25]. Overall, our findings based on

the limited number of studies, indicate that infection has a considerable impact on all aspects

of patients’ lives, and when undergoing treatment they can experience feelings of isolation and

insecurity, and an inability to live independently. Cahill and colleagues noted that more psy-

chological and social support was needed for this group of patients, given the negative impact

on their social functioning, and that the impact on mental health is notable. This group of

patients rated their overall quality of life as poor with 12% of patients rating their current situa-

tion as equivalent to or worse than death [24]. Andersson and colleagues reported inconsisten-

cies in care and the lack of an adequate patient-healthcare professional relationship in 14

patients who had acquired deep surgical site infection and had completed treatment [26]. The

study authors stressed the need for healthcare professionals to develop strategies to support

patients undergoing treatment for infection and also to involve patients in their care. Moore

and colleagues found that PJI and its treatment had a profoundly negative impact on many

aspects of patients’ lives and patients identified a clear need for additional physical, psycholo-

gical, social care and economic support both during and after treatment. The authors found

that two-stage revision treatment was associated with considerable physical and psychological

burden and further complications. No studies were identified that evaluated existing support

interventions (including physical rehabilitation, counselling, peer support, improved informa-

tion) for patients being treated for PJI or other major adverse events after joint arthroplasty.

Implications of our findings

Our results are relevant and provide new insight into the limited evidence available regarding

support needs and provision for patients undergoing treatment for PJI and other adverse

events after joint arthroplasty. Our review clearly identifies gaps in the literature. Although

for many people, hip and knee arthroplasty are highly successful and cost-effective interven-

tions for alleviating pain and disability associated with advanced joint disease, arthroplasty is

also associated with uncommon but serious complications, such as PJI [28, 29]. Patients who

undergo treatment with one-stage or two-stage revision surgery may experience sustained

psychological distress both during and after treatment, and further pain, disability, and even

poorer subsequent quality of life [24, 27]. Prosthetic joint infection and other complications

of joint arthroplasty constitute a major burden for patients and health systems as a whole

and with increasing numbers of operations being performed, the number of infections will

likely remain significant [30]. This review shows clearly there is a need for the development,



evaluation and implementation of effective care pathways that address the physical and psy-

chological trauma associated with complications after joint arthroplasty and their treatments

and to support patients at each stage of their diagnosis, treatment and recovery.

Strengths and limitations

This is the first review to identify a lack of evidence on support needs and interventions for

patients undergoing treatment for prosthetic joint infection or other major adverse occur-

rences following hip or knee arthroplasty. With a comprehensive literature search across

multiple databases, we identified 4 studies which provide evidence on the support needs of

patients being treated for PJI or other major adverse events following hip or knee replacement

and appropriate support interventions. The review was limited by the small number of hetero-

geneous studies that were identified. While the evidence is limited the general objective of a

systematic review is to identify best evidence and to evaluate it where it exists, as well as to

identify important gaps within the research evidence. These studies highlight the considerable

negative impact that these adverse events have on patients and identify their unmet needs,

while the lack of evidence also suggests there is a lack of service provision for this patient popu-

lation that needs to be addressed.

The eligible studies from the review were conducted in a diverse group of countries, which

may affect the generalisability of the findings; however, surgical practices around hip and knee

arthroplasty in these countries is similar, and our findings suggest that PJI has a similar nega-

tive impact on patients in each of these countries. In addition, none of the studies in each of

these countries evaluated existing support interventions for patients being treated for PJI or

other major adverse events after joint arthroplasty. There was a potential for biases in the

study designs used for the eligible studies as they employed observational and interpretive

designs. The findings cannot be generalised to other complications after joint arthroplasty as

all of the studies focused on surgical site infection.

Conclusions

In summary, our review shows that prosthetic joint infection can have a devastating impact on

patients and that patients need more physical, psychological and social support. There is a lack

of evidence on support strategies for patients undergoing treatment for PJI and other adverse

events. The limited evidence available suggests that there is a worrying lack of service provision

for these patients. This review highlights the need for the design, implementation, and evalua-

tion of integrated care pathways to support patients undergoing treatment for prosthetic

joint infection and other adverse outcomes following hip or knee replacement. Hip and knee

arthroplasty are common interventions for the treatment of painful joint conditions and the

increasing number of operations being performed means the number of prosthetic joint infec-

tions and other complications will remain significant. The development of care pathways that

address the psychological, social, emotional, and economic needs of patients experiencing

complications after hip and knee arthroplasty should be a research priority. Work is currently

underway within our research group to develop and implement a care pathway to address the

unmet needs of this patient group [31].

Supporting Information

S1 Appendix. PRISMA checklist.

(DOCX)



http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0169068.s001

S2 Appendix. Literature search strategy.

(DOCX)

S3 Appendix. Reference list of excluded studies.

(DOCX)

Acknowledgments

The authors would like to thank Amanda Burston and the INFORM Patient and Public

Involvement group and Jason Heddington for their support on the project.

Author Contributions

Conceptualization: AJM ADB RGH TJP MRW AWB SKK.

Data curation: SKK AJM.

Formal analysis: SKK AJM ADB.

Funding acquisition: AJM ADB RGH TJP MRW AWB.

Investigation: SKK AJM.

Methodology: SKK AJM ADB RGH TJP MRW AWB.

Project administration: AJM.

Software: SKK AJM.

Supervision: AJM.

Validation: ADB.

Visualization: SKK AJM ADB RGH TJP MRW AWB.

Writing – original draft: SKK AJM.

Writing – review & editing: AJM SKK RGH MRW TJP AWB ADB.

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http://dx.doi.org/10.1371/journal.pone.0151537


http://dx.doi.org/10.1186/1471-2474-14-222


http://dx.doi.org/10.3109/09638288.2011.603016


http://dx.doi.org/10.1302/0301-620X.95B11.33135


http://dx.doi.org/10.1001/jama.291.11.1358


http://dx.doi.org/10.2147/COPD.S74162


http://dx.doi.org/10.1136/bmj.a1655

http://dx.doi.org/10.1136/bmj.a1655


http://dx.doi.org/10.1371/journal.pmed.1000097

http://dx.doi.org/10.1371/journal.pmed.1000097



http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp




http://www.cardiff.ac.uk/insrv/libraries/sure/doc/SURE_RCT_Checklist_2013.pdf

http://www.cardiff.ac.uk/insrv/libraries/sure/doc/SURE_RCT_Checklist_2013.pdf

http://dx.doi.org/10.1054/arth.2000.16504

http://dx.doi.org/10.1054/arth.2000.16504


http://dx.doi.org/10.1016/j.ajic.2010.03.017


http://dx.doi.org/10.1136/bmjopen-2015-009495


http://dx.doi.org/10.1007/s11999-009-1013-5


30. Moran E, Byren I, Atkins BL. The diagnosis and management of prosthetic joint infections. Journal of

Antimicrobial Chemotherapy. 2010; 65(suppl 3):iii45–iii54.

31. Moore AJ, Heddington J, Whitehouse MR, Peters TJ, Gooberman-Hill R, Beswick AD, Blom AW. A UK

national survey of care pathways and support offered to patients receiving revision surgery for pros-

thetic joint infection in the highest volume NHS orthopaedic centres. Poster presented at the European

Orthopaedic Research Society 24th Annual Meeting, September 2016.



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